Oversees creation, maintenance, and governance of policies, procedures, desk-level workflows, and job aids across Core Admin Ops. Ensures documentation is aligned with current regulatory requirements, contractual obligations, and operational processes. Maintains structured documentation approval processes and version control to support audit readiness and compliance transparency. Partners with operational leaders and QA to ensure procedures align with audit findings, corrective actions, and quality standards.
Leads operational readiness planning for regulatory or contractual changes affecting claims payment, provider reimbursement, data requirements, notices, timelines, and related administrative rules. Collaborates with key stakeholders to identify impacts, design compliant solutions, and update training/materials. Develops and manages implementation plans for required changes, ensuring consistency across teams and sustainable compliance. Supports internal and external audits by preparing documentation, participating in sample review, and coordinating with QA and operational leaders. Tracks regulatory trends and proactively identifies potential compliance risks or exposure areas.
Develops and oversees corrective actions related to compliance gaps, operational deficiencies, and audit findings. Ensures corrective actions incorporate training, policy updates, and process changes to drive sustainable improvement. Partners key stakeholder to validate Corrective Action Plan (CAP) effectiveness through testing, monitoring, and data-driven assessments. Tracks patterns of compliance gaps and collaborates with operational leaders to implement preventive improvements.
Serves as the primary compliance advisor to operational leaders within cross functional business units. Supports management with regulatory interpretation, operational analysis, compliance risks, and recommended mitigation strategies. Represents Claims Compliance in governance meetings, operational readiness discussions, and regulatory working groups. Partners with Analytics and operational reporting teams to monitor compliance metrics, operational adherence, and trend analyses.
Manages, leads, trains, and develops a team responsible for training, documentation, compliance monitoring, and regulatory interpretation. Ensures staff maintain deep working knowledge of regulatory requirements and operational processes. Builds a culture grounded in data integrity, critical thinking, and supports proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement. Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Responsible for reporting, budgeting, and policy implementation.
Perform other duties as assigned.
